Transkript

1 Health Classifications in the Nordic Countries Historic development in a national and international perspective 2006 Hälsoklassifikationer i de nordiska länderna Den historiska utvecklingen i ett nationellt och internationellt perspektiv 2006

8 PREFACE Preface Förord At the present time, a new generation of experts working with classifications within the health sector is taking over. Although it is positive that young colleagues are interested in this important field, and that they are enthusiastic about this work, there is a risk that important knowledge about the development of the classification systems can be lost and forgotten. Since the end of the 19th century, classification of diseases has been an international matter. From working only with mortality statistics, national and international authorities have realized more and more that there is a need for improved knowledge about all aspects of health care including knowledge about diseases and their causes as a means of improving population health. In this context classification systems are important tools. During the years between the First and Second World Wars, the Nordic countries began to cooperate on health statistics and classifications. In the 1950s, influenced by international developments under the leadership of the World Health Organisation, they realized that this cooperation should be developed further. However, it became clear that the available statistics were developed in such different ways, that direct comparison of data from the five countries was difficult or even impossible. I disse år sker der et generationsskifte i gruppen af nordiske eksperter, der beskæftiger sig med klassifikationer inden for sundhedsvæsenet. Lige så positivt det er, at der også blandt nye medarbejdere er interesse for og engagement i dette vigtige område, lige så sikkert er det, at der er risiko for, at vigtig viden og erindring om klassifikationernes udvikling kan gå tabt. Siden slutningen af det 19. århundrede har sygdomsklassifikation været et internationalt anliggende. Fra kun at beskæftige sig med dødsårsagsstatistik har nationale og internationale myndigheder i større og større omfang erkendt behovet for øget viden om alle dele af sundhedsvæsenet og ikke mindst viden om sygdom og sygdomsårsager som middel til forbedring af folkesundheden. Klassifikationer er et vigtigt redskab i denne sammenhæng. De nordiske lande havde allerede i mellemkrigsårene påbegyndt et begrænset samarbejde om helsestatistik og klassifikationer, og i 1950 erne indså man under indtryk af den internationale udvikling på området under Verdenssundhedsorganisationens ledelse, at de nordiske lande burde samarbejde også på dette område. Det viste sig imidlertid, at de statistikker, der var til rådighed, var tilvejebragt på et så forskelligt grundlag, at direkte sammenligning mellem de fem lande var vanskelig for ikke at sige umulig. 8

9 PREFACE In 1966, this realization led to the formation of a committee under the Nordic Council of Ministers to remedy this shortcoming. The Nordic Medico-Statistical Committee (NOMESCO) has undertaken many tasks, first within health statistics, and later within coordination and development of classifications, with the aim of supporting common Nordic health statistics. Work with the development of classifications, and coordination with WHO and other international statistical bodies, led to the formation of a Nordic centre for classifications. After some years as a project under the Nordic Council of Ministers, in 1996 the Nordic Centre for Classification of Diseases was established as a Nordic institution financed directly by the health authorities of the five countries. On the occasion of NOMESCO s 40th anniversary, and the 10th anniversary of the Nordic Centre for Classification of Diseases as a Nordic institution in its own right, these two Nordic cooperation projects have shown their justification and viability. We have therefore asked two experts who will soon be retiring from their work with Nordic classifications to impart their knowledge and experience in the form of this publication. We wish to thank professor Björn Smedby and consultant Gunnar Schiøler for their willingness to undertake this task. Denne erkendelse førte i 1966 til dannelsen af en komite under Nordisk Ministerråd, som skulle råde bod på disse mangler. Nordisk Medicinalstatistisk Komite (NOMESKO) har påtaget sig mange opgaver først inden for helsestatistikken, men efterhånden også med koordination og udvikling af klassifikationer, som kunne understøtte en fælles nordisk helsestatisk. Arbejdet med udvikling af klassifikationer og med koordinationen til WHO og andre internationale statistiske institutioner førte efterhånden til dannelsen af et nordisk klassifikationscenter i Uppsala, som efter en årrække som projekt under Nordisk Ministerråd i 1996 blev omdannet til en fællesnordisk institution finansieret direkte af de fem landes sundhedsmyndigheder. I anledningen af NOMESKO s 40 års jubilæum og i 10-året for klassifikationscenterets oprettelse som permanent nordisk institution har disse to nordiske samarbejdsprojekter vist deres berettigelse og levedygtighed, og vi har derfor fundet det af interesse at bede to eksperter, der nu er ved trække sig ud af det daglige arbejde med klassifikationer i Norden, give deres viden og erfaring videre i form af denne publikation Vi takker professor Björn Smedby og overlæge Gunnar Schiøler, fordi de har villet påtage sig dette arbejde. Tromsø, June 2006 Tromsø, juni 2006 Mika Gissler Chair NOMESCO Formand NOMESKO Sveinn Magnússon Chair Nordic Centre for Classifications in Health Care Formand Nordisk Klassifikationscenter 9

10 INTRODUCTION 1 Introduction 1 Inledning The use of classifications is the oldest known method for studying the incidence of diseases and their consequences. First medical researchers and later statisticians and others developed and used classifications to reveal secrets behind the influences of diseases on individuals and society, and in this way to find ways and means of preventing the often very serious consequences of diseases. A classification of diseases must be based on current knowledge about the various conditions, their manifestations and their causes. From the time the first classifications of diseases saw the light of day more than 250 years ago until today, our knowledge about the causes of diseases and about related factors has expanded enormously. This means that today we can classify a great number of diseases based on their causes and nature. Consequently we can classify them more precisely and thus find new causal relationships, which are important for the treatment and prevention of diseases. A classification of diseases, as we understand it today, came into existence in the middle of the 19 th century on the initiative of the International Statistical Committee, which wanted to improve mortality statistics at that time the most important, internationally available source of knowledge of the impact of diseases on the health of the population. Classifica- Brugen af klassifikationer er den ældste kendte metode til at studere sygdommes forekomst og konsekvenser. Først har medicinske forskere og senere ikke mindst statistikere udviklet og brugt klassifikationer til at afsløre hemmelighederne bag sygdommes påvirkning af individer og samfund for derigennem at finde veje og måder til at forhindre de ofte meget alvorlige konsekvenser, de kan få. En klassifikation af sygdomme må i følge sagens natur bygge på den viden, man på et givet tidspunkt har om de enkelte sygdomme, deres manifestationer og deres årsager. Fra de første sygdomsklassifikationer så dagens lys for mere end 250 år siden til i dag er vores viden om årsager og sammenhænge udvidet næsten eksplosionsagtigt. Det betyder, at vi i dag kan klassificere et meget stort antal sygdomme ud fra årsag og natur. Følgelig kan vi også klassificere dem meget mere præcist og dermed finde nye og afgørende sammenhænge, der er af betydning for at behandle og forebygge dem. En sygdomsklassifikation i moderne forstand opstod i midten af det 19. århundrede på initiativ af den internationale statistikkomite, som ønskede at forbedre dødsårsagsstatistikken den dengang vigtigste, internationalt tilgængelige kilde til viden om sygdommes betydning for folkesundheden. Man fik udviklet klassifikationer baseret på datidens viden og 10

11 INTRODUCTION tions were developed based on current knowledge. At the end of the century internationally accepted groupings of the most important conditions were defined, and the diagnoses were used as causes of death. The development of natural science and medical science in the 20 th century led to great improvements in diagnostic possibilities and the accuracy of diagnoses. Diagnoses became more detailed both as causes of death and as descriptions of diseases in general. Classifications of diseases both national and international were developed accordingly in terms of the number of classified diagnoses. Due to the legitimate statistical need for longitudinal studies of overall health problems, a corresponding development in the structure of classifications, and in the principles they were based on, did not take place, and the international classification of diseases in the 21 st century can be directly traced back to the overall grouping that was laid down in the middle of the 19 th century. Classifications of causes of death, and slightly later diseases, were the first classifications that gained a footing in the health sector. A substantial incentive for this development was growing concern about the social problems that now come under the concept of public health an internationally used term which is only partly covered by the Nordic terms folkhälsa and folkesundhed. Later, when medical knowledge and capacity created a foundation for considerable and important new activities in the health sector, other classifications were developed. Examples are classifications of surgical procedures, radiological examinations, laboratory tests and nursing procedures. All these classifications mod slutningen af århundredet havde man internationalt accepterede grupperinger af de mest betydningsfulde sygdomsbilleder defineret, og diagnoserne anvendtes som dødsårsager. Det 20. århundredes natur- og lægevidenskabelige udvikling betød store fremskridt for de diagnostiske muligheder og deres præcision. En konsekvens var en stadigt større detaljering af diagnoserne både som dødsårsager og som betegnelser for sygdomme i al almindelighed. Sygdomsklassifikationer både den internationale og de nationale udviklede sig tilsvarende med hensyn til antal klassificerede diagnoser. På grund af statistikkens legitime behov for longitudinelle studier af de overordnede sundhedsproblemer, så man ikke en tilsvarende udvikling af klassifikationernes struktur og principper, og strukturen i det 21. århundredes internationale sygdomsklassifikation kan føres direkte tilbage til de overordnede grupperinger, som man fastlagde i midten af 1800-tallet. Klassifikationerne af dødsårsager og noget senere sygdomme var de første klassifikationer, som fik indpas i sundhedssektoren. En væsentlig drivkraft i denne udvikling var den stigende opmærksomhed på de samfundsproblemer, som i dag internationalt samles under begrebet public health et internationalt begreb, som kun delvis dækkes af nordiske termer som folkhälsa og folkesundhed. Senere da den medicinske kunnen og formåen skabte grundlaget for betydelige og betydningsfulde nye aktiviteter inden for sundhedssektoren, kom andre klassifikationer til. Her skal blot som eksempler nævnes klassifikationer af operationer, af radiologiske undersøgelser, af laboratorieundersøgelser og af sygeplejeprocedurer. Alle med hver deres betyd- 11

12 INTRODUCTION have importance for monitoring, analyzing and administrating complex and expensive modern health care systems. Modern computer technology makes collection of detailed data possible, and allows analysis and presentation of complex information. The situation was very different 150 years ago, when it was necessary to collect data and transform it into clear and understandable information manually. However, regardless of technical developments, classifications have the same central importance when dealing with crucial and complex elements in health care. Important areas of relevance for classifications include the incidence of diseases, use of resources, mortality, life expectancy, management and planning of health care systems and health institutions, and capacity and productivity studies. Other relevant areas are epidemiological and clinical research, development of new drugs and treatment, and evaluation of the need for and effects of public health measures in various sectors of society. Thus within the activities of health professionals, development and use of classifications have a very central role. It is therefore important that users have access to information about the origins of the classifications, the principles for the grouping of the concepts that are classified, and their development over time. The Nordic countries were active in this field at an early stage, but did not really enter into international collaboration until after the Second World War, when WHO become the coordinating body for international health statistics. Since then, however, the somewhat similar Nordic countries have become more and more involved in global ning for overvågning, analyse og administration af det meget komplekse og meget kostbare moderne sundhedsvæsen. Nutidens computerteknologi muliggør en meget detaljeret opsamling af data og en præsentation og analyse af de ofte meget komplekse informationer, der er til rådighed. Dette i modsætning til situationen for 150 år siden, da nødvendigheden krævede at indsamlede data manuelt kunne omdannes til overskuelige og forståelige informationer. Klassifikationerne har imidlertid uanset den tekniske udvikling den samme centrale betydning i behandlingen af de mest afgørende og vanskeligste elementer i sundhedsvæsnet. Det drejer sig om områder som sygdomsforekomst, ressourceanvendelse, dødsårsager og levetidsanalyser, ledelse og planlægning af sundhedsvæsner og enkeltinstitutioner, kapacitets- og produktivitetsstudier og meget mere, men også om epidemiologisk og klinisk forskning, udvikling af nye lægemidler og behandlingsmetoder samt vurdering af behov og effekt af public health-indsats på forskellige samfundsområder. Udvikling og anvendelse af klassifikationer har altså en helt central plads i sundhedsprofessionernes virksomhed. Det er derfor vigtigt at brugerne har adgang til viden om klassifikationernes tilblivelse, principperne for deres ordning af begreberne og deres udvikling over tid. De nordiske lande har tidligt være aktive på dette område, men kom først for alvor ind i den internationale sammenhæng efter 2. verdenskrig, da WHO blev den koordinerende institution i international sundhedsstatistik. Siden har vores temmelig ensartede lande imidlertid med stigende energi engageret sig i den globale udvikling på området. Det 12

13 INTRODUCTION developments in this area, with growing enthusiasm. This has taken place through close cooperation between the countries. But there have also been different points of view, and disagreements at times, which have required time and good will to overcome. But the cooperation has mostly been fruitful and very useful. We have created common institutions for health statistics and classifications, and together we have developed classifications that are used uniformly in our health services. This has given us a common professional platform, with the result that we are heard in international fora in which health classifications and statistics are developed. Nordic cooperation that has taken place, in work with classifications at the international, Nordic and country levels, will be described in this publication. The cooperation between the Nordic countries is unique, and is respected internationally. In spite of differences in language and culture, we have been able to develop uniform classifications, which have made it possible to produce the best possible comparable health statistics covering several countries. Hopefully this book will make a useful contribution to the documentation of this long and fascinating history. During the process of writing this history, we have used numerous written sources both in archives and in published literature. Many of these references are in the list of references, but we are also indebted to many persons, who are or have been active in the Nordic cooperation on classifications. The work of NOMESCO during the early years is poorly documented in the archives, but we have received valu- er sket i et tæt samarbejde landene imellem, men ikke uden afvigende synspunkter og til tider uenigheder, der har krævet tid og god vilje at overvinde. Mest har samarbejdet dog været frugtbart og meget nyttigt. Vi har skabt fælles institutioner for sundhedsstatistik og klassifikationer, og vi har sammen udviklet store klassifikationer, der bruges ensartet i vores sundhedsvæsener. Det har givet en faglig platform, der har betydet, at vi bliver hørt i de internationale fora, der beskæftiger sig med klassifikationer og statistik inden i sundhedssektoren. Det er en del af dette nordiske samarbejde, der skal beskrives i denne publikation, som beskæftiger sig med forløbet af klassifikationsarbejdet internationalt, fælles nordisk og i de enkelte nordiske lande. De nordiske landes samarbejde er unikt og almindeligt respekteret internationalt. Vi har formået trods sproglige og kulturelle forskelligheder at udvikle ensartede klassifikationer, der har gjort det muligt at producere de bedst mulige sammenlignelige sundhedsstatistikker, der omfatter flere lande. Forhåbentlig vil denne publikation give et nyttigt bidrag til belysningen af den lange og spændende historie. Under arbejdet med den har vi kunnet støtte os til mange skriftlige kilder både i arkiver og i publiceret form. I referencelisten kan mange af dem findes, men vi skylder også tak for den hjælp vi har fået fra personer, der er eller har været aktive i det nordiske klassifikationssamarbejde. De tidligste år i NOMESKOsamarbejdet er kun dårligt dokumenter i arkiverne, men vi har fået værdifuld 13

15 THE HISTORY OF CLASSIFICATION OF DISEASES 2 The history of the classification of diseases 2 Sjukdomsklassifikationens historia International developments The first real classifications of diseases were developed in the middle of the 18th Century. The Frenchman François Boissier de Sauvages published Nosologia methodica in 1731, and later, in 1763, Carl von Linné published Genera morborum, which was based on Sauvage s classification. In 1785 William Cullens, in Edinburgh, published Synopsis nosologiae methodicae, which came to be the most important classification well into the 19 th century Linné s classification [1] which is of special interest in relation to the Nordic countries included 11 classes, 37 groups and 325 types of diseases, and was inspired by Linné s earlier work with classifications in the field of botany. For Linné and his contemporaries, interest in classifications was determined by the need for an overview of diseases and the need to systematize knowledge about diseases, in order to reveal the inherent order in nature. Because the medical knowledge that the work was based on was incomplete, a purely descriptive approach was necessary, and the classification was characterized by an underlying philosophy of nature that had a large speculative element it was a philosophical system. Den internationella utvecklingen De första egentliga sjukdomsklassifikationerna tillkom i mitten av 1700-talet. Då publicerade först fransmannen François Boissier de Sauvages sin Nosologia methodica år 1731 och därefter Carl von Linné år 1763 sin Genera morborum som byggde på Sauvages klassifikation. År 1785 publicerades sedan i Edinburgh William Cullens Synopsis nosologiae methodicae som kom att bli den dominerande klassifikationen långt in på 1800-talet. Linnés klassifikation [1] som är av särskilt intresse i ett nordiskt sammanhang omfattade 11 klasser, 37 ordningar och 325 arter av sjukdomar och var inspirerad av hans tidigare klassifikationsinsatser inom botanikens område. För Linné och hans samtid var intresset för en sjukdomsklassifikation betingat av ett behov av överblick och system i kunskapen om sjukdomarna för att avslöja naturens inneboende ordning. Den ofullständiga medicinska kunskap som arbetet byggde på nödvändiggjorde en rent deskriptiv ansats och klassifikationen präglades av en bakomliggande naturfilosofi med starkt spekulativa inslag den blev ett filosofiskt system. 15

16 THE HISTORY OF CLASSIFICATION OF DISEASES It is interesting to note that Linné s classification does not seem to have had much influence on the list of causes of death that the clergy used for reporting deaths, that was introduced in connection with the early Swedish population statistics. The need for simple statistics and comparisons determined the way this was reported. The statistical approach has also characterized later work with classifications of diseases and causes of death. In the middle of the 19 th century, William Farr worked in London as the first publically employed medical statistician. He worked with statistics of deaths in the city. He pointed out the need for standardized nomenclature and classification. In 1853, together with his Swiss colleague Marc d Espine, he was given the task by the first International Statistical Congress of making a proposal for a classification of causes of death. Farr divided causes of death into five main groups: Epidemic diseases Constitutional, general diseases Local, anatomically ordered diseases Developmental disorders Injuries caused by violence At the next international congress in Paris in 1855, Farr s proposal was mainly accepted, as a list of 139 codes. The list was revised several times during the 19 th century, but was never generally accepted. However, the basic structure of Det är intressant att notera att Linnés klassifikation inte tycks ha fått något egentligt inflytande på den lista av dödsorsaker som kom att gälla för prästerskapets rapportering av dödsorsaker som infördes i samband med den tidiga svenska befolkningsstatistiken. Då var det behovet av enkla statistiska översikter och jämförelser som fick styra utformningen. Den statistiska ansatsen har också dominerat för senare tiders arbete med klassifikationer av sjukdomar och dödsorsaker. Vid 1800-talets mitt verkade i London William Farr som den förste offentligt anställde medicinska statistikern. Han arbetade med statistiska sammanställningar av dödsfallen i staden. Han påtalade behovet av en standardiserad nomenklatur och klassifikation. År 1853 fick han av den första internationella statistiska kongressen i uppdrag att tillsammans med sin schweiziska kollega Marc d Espine göra ett förslag till en statistisk dödsorsaksklassifikation. Farr delade in dödsorsakerna i fem stora grupper: Epidemiska sjukdomar Konstitutionella, generaliserade sjukdomar Lokaliserade, anatomiskt ordnade sjukdomar Utvecklingsrubbningar Skador orsakade av yttre våld Vid den följande internationella kongressen i Paris 1855 antogs i stort sett Farrs förslag som en lista med 139 rubriker. Denna lista reviderades flera gånger under senare delen av 1800-talet men blev aldrig allmänt accepterad. 16

17 THE HISTORY OF CLASSIFICATION OF DISEASES Farr s classification was preserved in a new proposal that the Frenchman Jaques Bertillon put forward at the International Statistical Institute s meeting in 1893 in Chicago. At this meeting, the first International List of Causes of Death (ICD) was adopted. It was later decided that the list should be revised every tenth year. A series of international revision conferences was then held, under the initiative of the French Government, led by Bertillon until his death in Table 1 gives a list of the revision conferences, and shows the increase in the number of codes as a result of the revisions. The Health Organization of the League of Nations also participated in the work with the fourth (1929) [2] and the fifth (1938) [3] revisions. Grundstrukturen i Farrs klassifikation kom emellertid att leva kvar i ett nytt förslag som fransmannen Jaques Bertillon lade fram vid det internationella statistiska institutets möte 1893 i Chicago. Då fastställdes den första International List of Causes of Death (ICD). Man bestämde senare att listan skulle revideras vart tionde år. Så skedde också vid en serie internationella revisionskonferenser som den franska regeringen tog initiativ till och som leddes av Bertillon till hans död Serien av revisionskonferenser och det inflytande dessa haft på klassifikationens omfattning framgår av tabell 1. I revisionsarbetet för den fjärde (1929) [2] och den femte (1938) [3] revisionen deltog även Nationernas Förbunds hälsoorganisation. Table 1 The development of ICD Version Year for revision Number of codes ICD ICD ICD ICD ICD ICD ICD ICD ICD ICD ICD In the work with revisions in the 1930s and 1940s, the increasing need for a classification that could also be used for morbidity statistics was identified, and proposals for classifications of diseases and injuries were presented in several countries, including Canada, Great Britain and the USA. However, a common international I revisionsarbetet konstaterades under och 1940-talen ett ökande behov av en klassifikation som även kunde användas för morbiditetsstatistik och förslag till klassifikationer av sjukdomar och skador presenterades i olika länder, bl.a. Canada, Storbritannien och USA. En gemensam internationell klassifikation för 17

18 THE HISTORY OF CLASSIFICATION OF DISEASES classification of diseases and causes of death was first developed at the sixth revision conference in Paris in 1948, organized by the newly established World Health Organisation (WHO). It was given the name International Statistical Classification of Diseases, Injuries and Causes of Death (ICD-6) [4]. At the same time, an international form for death certificates was adopted, and standardized regulations for the selection of underlying cause of death were established, which was important for international comparability. Short lists suitable for tables of morbidity and mortality were also adopted. WHO published the classification in English, French and Spanish. Later, at the suggestion of the Scandinavian countries, an alphabetical register in Latin was developed by the Danish professor H.C. Gram [5]. Further revisions have all been made by WHO. The seventh revision (1955) [6] was limited to correction of errors and inconsistencies. The eighth revision (1965) [7] was more extensive, but retained the classification s structure and the general principle that as far as possible diseases were classified according to etiology rather than manifestation. During the time when ICD-7 and ICD- 8 were used, the classification also began to be used for coding of hospital patient records and patient statistics. This led to several countries, including the Nordic countries, making national adaptations that allowed a greater level of detail (more about this below). Initially, the ninth revision (1975) [8] was to be limited, but the interest of various groups of medical specialists for ICD-9 was so great, that the revision led to both restructuring of some sections sjukdomar och dödsorsaker förverkligades dock först vid den sjätte revisionskonferensen som hölls i Paris 1948, organiserad av den nybildade världshälsoorganisationen (WHO). Den fick namnet International Statistical Classification of Diseases, Injuries and Causes of Death (ICD-6) [4]. Samtidigt fastställdes ett internationellt formulär för dödsbevis och enhetliga regler för val av underliggande dödsorsak, vilket var viktigt för den internationella jämförbarheten. Förkortade listor lämpade för tabulering av morbiditet och mortalitet fastställdes också. WHO publicerade klassifikationen på engelska, franska och spanska. På förslag av de skandinaviska länderna tillkom senare även ett alfabetiskt register på latin som utarbetats av den danske professorn H.C. Gram [5]. De följande revisionerna har alla skett genom WHO:s försorg. Den sjunde (1955) [6] begränsades till rättning av felaktigheter och inkonsekvenser. Den åttonde (1965) [7] var mer omfattande men behöll klassifikationens struktur och den allmänna principen att så långt som möjligt klassificera sjukdomarna efter etiologi snarare än manifestation. Under den tid som ICD-7 och ICD-8 gällde började klassifikationen alltmer användas även för indexering av sjukhusjournaler och patientstatistik, vilket ledde till att flera länder, däribland de nordiska, gjorde nationella anpassningar som erbjöd större detaljeringsgrad (mera härom nedan). Den nionde revisionen (1975) [8] avsågs från början bli begränsad, men intresset för ICD-9 hade blivit så stort från olika medicinska specialistgruppers sida att revisionen ledde både till om- 18

19 THE HISTORY OF CLASSIFICATION OF DISEASES and to increased level of detail. In addition, the so-called dagger-asterisk system was introduced. This allows, for some diseases, for the optional possibility to code not just the underlying general etiology but also the manifestation of the disease in different organ systems. Several other changes were also introduced in the regulations for the application of the classification for both mortality and morbidity. For the tenth revision, it was no longer possible to keep the traditional ten-year interval, because work with the revision was so extensive. The revision conference was not held until 1989, and a few more years went by before ICD-10 could be published, now in the form of three different volumes: a systematic, tabular list (1992) [9], an instruction manual (1993) [10] and an alphabetical index (1994) [11]. ICD-10 involved a greatly increased number of codes and greater level of detail, primarily with the many clinical applications in mind. Despite a certain amount of criticism, the dagger-asterisk system was kept and extended. As a result of developments in medical knowledge, some restructuring was done, so that some diseases and groups of diseases were moved to other chapters. The number of chapters was increased, because some chapters were divided up, and because the so-called external cause codes were incorporated into the main classification. The code structure was changed from purely numerical to alphanumerical, in order to allow for a greater number of codes and more detailed codes. The regulations for application of the classification were modified and expanded, regarding both mortality and morbidity. The primary application of strukturering av vissa avsnitt och till ökad detaljeringsgrad. Man införde också det s.k. dagger-asterisksystemet, vilket innebar en valfri möjlighet att för vissa sjukdomar koda inte bara den bakomliggande generella etiologin utan även deras manifestation i olika organsystem. Flera ändringar infördes också i regelverket för klassifikationens tillämpning beträffande både mortalitet och morbiditet. För den tionde revisionen kunde man inte längre behålla det traditionella tioåriga intervallet på grund av revisionsarbetets stora omfattning. Revisionskonferensen hölls först 1989 och det dröjde ytterligare några år innan ICD-10 kunde publiceras, nu i form av tre olika delar; en systematisk del (1992) [9], en instruktionsmanual (1993) [10] och en alfabetisk del (1994) [11]. ICD-10 innebar ett starkt utökat antal koder och större detaljeringsgrad, främst med tanke på de många kliniska tillämpningarna. Trots viss kritik behölls daggerasterisksystemet och utökades. Med anledning av den medicinska kunskapsutvecklingen gjordes flera omstruktureringar innebärande flyttning av sjukdomar och sjukdomsgrupper mellan kapitel. Antalet kapitel utökades genom uppdelningar och inkorporering av de s.k. yttre orsaks-koderna i själva huvudklassifikationen. Kodstrukturen ändrades från rent numeriska till alfanumeriska koder för att ge utrymme för flera och mer detaljerade koder. Regelsystemet för klassifikationens användning modifierades och utvidgades beträffande både mortalitet och morbiditet. Klassifikationens primärt statistis- 19

20 THE HISTORY OF CLASSIFICATION OF DISEASES the classification for the purpose of statistics was emphasized by the name International Statistical Classification of Diseases and Related Health Problems, and the abbreviation ICD was kept. A detailed description of the growth and development of the international classification is to be found in Volume 2 of ICD-10 [10]. Despite the comprehensive changes that have been made to ICD during its long development, one can still clearly trace the basic structure that was proposed by William Farr more than 150 years ago. Farr s work had a clear public health approach. The aim was that the statistics should be used as an aid in the fight against infections and for improving environmental health, for reducing maternal and child mortality, and for preventing occupational diseases and accidents. It can be said that the public health problems of the time have left their mark on the classification. But it should be emphasized that in large parts of the world it is these problems that actually are the all-pervading health problems today. In WHO s global perspective it is therefore still the public health aspects that are the most important in work with classifications. ka användning underströks genom namnet International Statistical Classification of Diseases and Related Health Problems, och man bibehöll förkortningen ICD. En utförlig historisk beskrivning av den internationella sjukdomsklassifikationens framväxt och utveckling återfinns i volym 2 av ICD-10 [10]. Trots de stora förändringar som skett under den långa utvecklingen av ICD kan man fortfarande tydligt spåra den grundstruktur som förslogs av William Farr för mer än 150 år sedan. Farrs arbete hade en klar public health-inriktning. Det innebar att statistiken skulle vara till ledning för infektionsbekämpande och omgivningshygien, för förebyggande av mödra- och barnadödlighet och för prevention av yrkessjukdomar och olycksfallsskador. Man kan säga att den tidens folkhälsoproblem har satt bestående prägel på klassifikationen. Men det är värt att påpeka att i stora delar av världen är det just dessa frågor som utgör de helt överskuggande hälsoproblemen. I WHO:s globala perspektiv är det därför fortfarande public health-aspekterna som är de viktigaste i klassifikationsarbetet. Early registration of mortality in the Nordic countries Registration of causes of death started early in the Nordic countries, but in the beginning it took place without any real coordination between the countries. Also, to begin with, the Nordic countries did not participate actively in the international work with nomenclature under the leadership of Bertillon. As in several Den tidiga nordiska dödsorsaksregistreringen Registrering av dödsorsaker startade tidigt i de nordiska länderna men skedde till en början utan någon egentlig samordning mellan länderna. Från början deltog inte heller de nordiska länderna särskilt aktivt i det internationella nomenklaturarbetet under Bertillons ledning. Liksom i flera andra länder behöll 20

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